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NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> oOWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> (fm04C vh1//, <br /> FACILITY NAME <br /> t6170 C 0 T/I1"I S gi G 1 / <br /> SITE ADDRESS <br /> CLCy6t)C GrAOfc WW <br /> o Street Number Direction Street Name Cit Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) e ` a � <br /> ; J e. Iree11•Number Street ame <br /> CITY STATE ZIP ✓ <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#TT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR& 1 j9% iy CHECK if BILLING ADDRESS CI <br /> PHONE# �T• <br /> BUSINESS NAME 'J j,_ � I J T3 Z <br /> HOME or MAILING ADDRESS FAX# <br /> 53 �� m I Y I j'-k" <br /> CITY STATE,.'-/�_ ZIP u J s <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. '� <br /> ! DATE: t _ �(] <br /> APPLICANT'S SIGNATURE:„ iii1i�• rs � -f <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 1251j �U2 C CG�:Y Ivy ✓ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. — <br /> TYPE OF SERVICE REQUESTED: RECE VVEE) <br /> COMMENTS: D I-( t4 Z007 <br /> l 2-A)11o7 2- SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> lk D <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: ?j <br /> Fee Amount: 2 �' Amount Paid h 1 4- 0 Payment Date t 2 <br /> L4 107 <br /> Payment Type Invoice# Check# Received By: , <br /> EHD 48-02-025 ' ,SR'FORM(Golclen'Rod) <br /> REVISED 11/17/2003 <br />